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Virginia Administrative Code
Title 14. Insurance
Agency 5. State Corporation Commission, Bureau of Insurance
Chapter 410. Rules Governing Multiple Employer Welfare Arrangements
8/11/2020

Forms (14VAC5-410)

Policy Verification Form (eff. 6/93).

Proof of Coverage Form (eff. 6/93).

Demographic Information (eff. 6/93).

Biographical Affidavit (eff. 6/93).

Other Title 14 Forms

ANNUAL STATEMENTS

COMPANY TYPE

Life and Accident and Health, Form 1.

Canadian Life and Accident and Health, Form 1-A.

Life and Accident and Health, Separate Accounts, Form 1-S.

Fire and Casualty, Form 2.

Fraternal Orders, Form 4.

Assessment Life and Accident, Form 5.

Title Insurance, Form 9.

Hospital, Medical and Dental Service or Indemnity Corporation, Form 13.

Mutual Assessment Property and Casualty (eff. 1988).

SUPPLEMENTS TO THE ANNUAL STATEMENT

Credit Insurance Experience Exhibit, CIEE 2, 3, 4, 5, 6 and 7 (eff. 1992).

Insurance Expense Exhibit, IEE 2, 3, 4, 5, 6, 7 and 8.

Financial Guaranty Insurance Exhibit.

Stockholders Information Supplement, Schedule SIS (eff. 1992).

Fraternal Interest Sensitive Life Insurance Products Reports, FISL 3 and 4 (eff. 1993).

Life and Accident and Health Blank Interest Sensitive Life, ISL 2, 3, and 4 (eff. 1993).

Long Term Care Insurance Exhibit, Supplement to the Fraternal Order Annual Statement (eff. 1993).

Long Term Care Insurance Exhibit, Supplement to the Life Insurance Company Annual Statement (eff. 1993).

Accident and Health Policy Experience Exhibit, Form 0-9.

Fire and Casualty Supplemental Long-Term Care Experience Nationwide Experience Claim Experience By Calendar Duration.

Fire and Casualty Supplemental Long-Term Care Experience Nationwide Experience Cumulative Claim Experience.

Fire and Casualty Supplemental Long-Term Care Experience Experience in the State of... Cumulative Claim Experience.

Fraternal Orders Supplemental Long-Term Care Experience Nationwide Experience Claim Experience By Calendar Duration.

Fraternal Orders Supplemental Long-Term Care Experience Nationwide Experience Cumulative Claim Experience.

Fraternal Orders Supplemental Long-Term Care Experience Nationwide Experience Experience in the State of... Cumulative Claim Experience.

Life and Accident and Health Supplemental Long-Term Care Form-A Nationwide Experience Claim Experience By Calendar Duration, Form 4.

Life and Accident and Health Supplemental Long-Term Cure Form-B Nationwide Experience Cumulative Claim Experience By Calendar Duration, Form 4.

Life and Accident and Health Supplemental Long-Term Cure Form-C Experience in the State of... Cumulative Claim, Form 4.

Fraternal Benefit Societies-Supplement to Valuation Report (eff. 1978).

Schedule DM (eff. 1992).

Schedule DS - Part 2 (eff. 1993).

Analysis of Excess Capital and Surplus Investments, SCCBOI-4 (eff. 11/93).

Application for Renewal of License, SCCBOI-1A.

Application for Renewal of License (Chapter Companies), SCCBOI-1B.

Application for Renewal of License (HMDI), SCCBOI-8.

Report of Assets Pledged, Hypothecated or Encumbered, SCCBOI-17 (eff. 8/92).

Report of Assets Pledged, Hypothecated or Encumbered, SCCBOI-18 (eff. 8/92).

Report of Assets Pledged, Hypothecated or Encumbered, SCCBOI-19 (eff. 8/92).

Report of Assets Pledged, Hypothecated or Encumbered, SCCBOI-20 (eff. 8/92).

Request for Information Regarding Managing General Agent, SCCBOI-21 (eff. 10/93).

Request for Information Regarding Reinsurance Intermediaries, SCCBOI-22.

Affidavit for Exemption from Filing Audited Financial Reports, SCCBOI-16.

Producer Controlled Insurer Report, SCCBOI-23 (eff. 11/93).

Exhibit of Subscriber Fee Income and Net Administrative, SCCBOI-PP.

Supplementary Exhibit of Direct Subscriber Income by State.

Certificate of Assuming Insurer, RENFORMS (14VAC5-410)2 (eff. 10/93).

Appointment of Agent (Purchasing Group).

Appointment of Agent (Risk Retention Group).

QUARTERLY STATEMENTS

Life and Accident and Health, L, A&H-Q (eff. 94).

Fire and Casualty, F&C-Q (eff. 94).

Fraternal Orders, FO-Q (eff. 94).

Assessment Life and Accident, Form 5.

Title Insurance, T-Q (eff. 1994).

Hospital, Medical and Dental Service or Indemnity Corporation, FMDI-Q (eff. 1994).

COMPANY LICENSING FORMS (14VAC5-410)

Application for Initial License.

Application for Initial License (Home Protection Companies).

Estimated Premium License Tax.

Maintenance Assessment for BOI.

Fire Program Fund Report.

Flood Prevention & Protection Assistance Report.

Help Eliminate Auto Theft (HEAT).

Premium License Tax Report - Fire Casualty and Title Insurers, T001 (eff. 1/94).

Premium License Tax Report - Life, Accident and Sickness Insurers, T002 (eff. 1/94).

Report of Subscriber Income Premium License Tax - Legal Service Plans, T003 (eff. 11/93).

Report of Subscriber Income Premium License Tax - Limited Health Service Organizations Dental and Optometric Services Plans, T004 (eff. 1/94).

Report of Subscriber Income Premium License Tax - Health Service Plans, T005 (eff. 1/94).

Premium License Tax Report - Risk Retention Groups, T006 (eff. 1/94).

Report of Subscriber Income Premium License Tax - Mutual Assessment Property and Casualty Insurers, T007 (eff. 1/94).

Report of Subscriber Income Premium License Tax - Cooperative Non-profit Life Benefit Companies Mutual Assessment Life, Accident & Sickness Insurers, and Burial Societies, T008 (eff. 1/94).

Report of Premium Income/Maint. Assessment - Fraternal Benefit Societies, T020 (eff. 1/94).

Maint. Assessment Report - Fire, Casualty and Title Insurers, T021 (eff. 1/94).

Report of Income/Maint. Assessment - Mutual Assessment Property & Casualty Insurers, T022 (eff. 1/94).

Report of Income/Maint. Assessment - Cooperative Non-profit Life Benefit Companies; Mutual Assessment Life; Accident & Sickness Insurers; and Burial Societies, T023 (eff. 1/94).

Report of Subscriber Income/Maint. Assessment - Health Maintenance Organizations, T024 (eff. 1/94).

HEALTH MAINTENANCE ORGANIZATIONS

Annual Statement.

Quarterly Statement.

Application for Renewal of License in Virginia (HMO), HMO-1A.

Annual Complaint Report (HMO), SCCBOIHMO-9.

Statement of Material Changes in Material Previously Filed, SCCBOIHMO-10.

STATUTORY FORMS (14VAC5-410)

Report of Subscriber Income/Maint. Assessment - Legal Service Plans, T025 (eff. 1/94).

Report of Subscriber Income/Maint. Assessment - Limited Health Service Organizations/Dental and Optometric Services Plans, T026 (eff. 1/94).

Report of Subscriber Income/Maint. Assessment - Health Service Organizations, T027 (eff. 1/94).

Report of Premium Income/Maint. Assessment - Members of Group Self-Insurance Associations, T028 (eff. 1/94).

Maint. Assessment Report - Life, Accident and Sickness Insurers, T029 (eff. 1/94).

Maint. Assessment Report - Risk Retention Group, T030 (eff. 1/94).

Fire Programs Fund Report, T041 (eff. 1/94).

Flood Prevention & Protection Assistance Fund Assessment Report, T042 (eff. 1/94).

HEAT Fund Assessment Report, T043 (eff. 1/94).

Retaliatory Tax Report, T050.

Guaranty Fund Credit Affidavit, T051 (eff. 1/94).

Declaration of Est. License Tax and Est. Assessment, T060 (eff. 1/94).

Application for license when No Examination is required, PIN 405A (eff. July 1994).

Application for License, PIN 300A (eff. April 1994).

Agency Application for License, PIN 405B (eff. August 1994).

Application for Individual Consultant License, PIN 370A (eff. July 1994).

Application for Managing General Agent License, PIN 200A (eff. July 1994).

Automobile Club License and Application Form, PIN 320A (eff. July 1994).

Individual Appointment Form, PIN 415A (eff. July 1994).

Managing General Agent Appointment Notification, PIN 200B (eff. July 1994).

Agency Application Form, PIN 415B (eff. July 1994).

Appointment Cancellation Form, PIN 492A (eff. July 1994).

Consultant License Renewal Request, PIN 370B (eff. July 1994).

Renewal Application for Certification.

Application for Certification as a Private Review Agent.

Continuing Care Provider Registration Statement.

Website addresses provided in the Virginia Administrative Code to documents incorporated by reference are for the reader's convenience only, may not necessarily be active or current, and should not be relied upon. To ensure the information incorporated by reference is accurate, the reader is encouraged to use the source document described in the regulation.

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